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This invention provides combination therapy methods, pharmaceutical
combinations and compositions for inducing tumor cell regression in cancer
patients, particularly metastatic breast cancer patients. The combination
methods, combinations and compositions employ both edatrexate and a taxane
which are administered simultaneously or sequentially. The combination
therapy described here permits the administration of unusually high doses
of edatrexate.

1. A method to induce enhanced regression of a tumor in a human breast cancer patient without side effects comprising administering to a patient having breast cancer a
nontoxic dose of edatrexate of about 180 mg/m.sup.2 up to about 400 mg/m.sup.2 in a combination therapy with a nontoxic dose of a taxane derivative selected from the group consisting of paclitaxel, docetaxel and deoxygenated paclitaxel.

2. The method of claim 1, further wherein the taxane derivative is administered within 3 to about 24 hours after the edatrexate is administered.

3. The method of claim 1, further wherein about 135 mg/m.sup.2 to about 175 mg/m.sup.2 of the taxane derivative is administered after edatrexate is administered.

4. The method of claim 1, wherein the taxane derivative is paclitaxel.

5. The method of claim 1, wherein the taxane derivative is paclitaxel and is administered intravenously.

6. The method of claim 1, wherein the taxane derivative is paclitaxel and is administered intravenously together with the edatrexate.

7. The method of claim 1, wherein the dose of edatrexate is administered to the patient at a rate of one dose every three weeks.

8. The method of claim 1, wherein the taxane derivative is administered after the edatrexate, but within twenty-four hours of the edatrexate.

9. The method of claim 1, wherein the therapy further includes an immunosuppressive agent.

10. The method of claim 1, wherein the patient has metastatic breast cancer.

11. The method of claim 1, wherein the patient has not responded to a prior chemotherapeutic agent which was administered to the patient.

12. The method of claim 1, wherein the dose of edatrexate is about 240 mg/m.sup.2.

13. A method to induce enhanced regression of a tumor in a human breast cancer patient without side effects comprising administering to said patient a pharmaceutically acceptable formulation of edatrexate at a nontoxic unit dosage of about 180
mg/m.sup.2 or greater and concurrently administering to said patient a taxane derivative at a nontoxic unit dosage, wherein the taxane derivative is selected from the group consisting of paclitaxel, docetaxel and deoxygenated paclitaxel.

14. The method of claim 13, wherein the nontoxic dosage of edatrexate is about 180 to about 400 mg/m.sup.2.

15. The method of claim 13, wherein the taxane derivative is paclitaxel.

16. The method of claim 14, wherein the nontoxic dosage of a taxane derivative is about 135 to about 300 mg/m.sup.2.

17. The method of claim 16, wherein the taxane derivative is paclitaxel.

18. A method to induce enhanced regression of a tumor in a human breast cancer patient without side effects comprising administering to said patient a pharmaceutically acceptable formulation of edatrexate at a nontoxic unit dosage of about 180
mg/m.sup.2 to about 400 mg/m.sup.2 and concurrently administering to said patient paclitaxel at a nontoxic unit dosage of from about 135 mg/m.sup.2 to about 300 mg/m.sup.2.

19. A pharmaceutical combination for enhanced regression of a tumor in a human breast cancer patient without side effects comprising a unit dosage of edatrexate in an amount of about 180 mg/m.sup.2 up to about 400 mg/m.sup.2 and a nontoxic unit
dosage of paclitaxel.

20. A pharmaceutical combination for enhanced regression of a tumor in a human breast cancer patient without side effects comprising a nontoxic unit dosage of a taxane derivative and a unit dose of edatrexate in an amount effective to provide
edatrexate in a nontoxic unit dosage of about 180 mg/m.sup.2 up to about 400 mg/m.sup.2 to a human patient wherein the taxane derivative is selected from the group consisting of paclitaxel, docetaxel and deoxygenated paclitaxel.

Description

FIELD OF THE INVENTION

This invention relates to a combination therapy of a taxane and edatrexate to treat various cancers, including breast cancer.

BACKGROUND OF THE INVENTION

Breast cancer is the most common malignancy among women and along with lung cancer has the highest fatality rate of all cancers affecting women. The search for new active agents and strategies to improve the prognosis for patients with
metastatic breast cancer continues. In spite of the existence of numerous chemotherapeutic agents and regimens found to have antitumor activity, research continues in an effort to find improved treatment modalities, since survival rates in certain
cancers remain low. For example, less than one in five patients with Stage IV (advanced) breast cancer survives more than five years after distant metastases are detected.

Methotrexate has been one of the standard anti-tumor agents in the treatment of breast cancer. Edatrexate (10-ethyl-10-deaza-aminopterin) is a relatively new structural analog of methotrexate which was developed at the Memorial Sloan-Kettering
Cancer Center in New York in collaboration with SRI International. Like methotrexate, edatrexate inhibits dihydrofolate reductase. However, edatrexate is deemed a promising alternative because in preclinical tests it proved to have a greater antitumor
activity than methotrexate against a number of tumors, partly attributed to the fact that this new analog accumulated in sensitive tumor cells to a greater extent than its predecessor methotrexate and was more selectively retained by the tumor cells.
See, e.g. Kris et al., Cancer Research 48:5573-5579 (1988) and Sirotnak et al., NCI Monographs, No. 5 (1987).

The use of edatrexate as a single agent treatment against various tumors has met with some success. Studies of non-small cell lung cancer patients have reported positive results, with response rates being in the range of 30%. Grant et al.,
Cancer Investigation 11:36-45 (1993). Antitumor activity of edatrexate has also been observed in patients with non-Hodgkin's lymphoma, head and neck carcinoma, and breast cancer. (Vandenberg et al., Proc. Am. Soc. Clin. Oncol. 11:51 (1992);
Schornagel et al., Ann. of Oncology 3:549-552 (1992). No anti-tumor activity was observed in patients with smallcell lung cancer or metastatic colorectal carcinoma. See Grant et al., supra, for a general review of clinical trials with edatrexate.

Edatrexate has also been tested to a certain extent with other various agents in patients with non-small cell lung cancer. For example, positive responses have been reported from the administration of edatrexate with mitomycin and vinblastine
(Kris et al., Proc. Am. Soc. Clin. Oncol. 9:229 (1990) and with cisplatin and cyclophosphamide (Lee et al., Cancer 68:959-964 (1991). See, also, Grant et al., supra.

As with other chemotherapeutic drugs, dosages of edatrexate have been limited because of toxic effects of the drug. The primary toxic effect of edatrexate is mucositis, but leukopenia, thrombocytopenia and myelosuppression also occur. Due to
side effects, dosages of edatrexate have been, prior to the invention described below, limited to a range of 80 mg/m.sup.2 body surface area/week, with dosages of up to 120 mg/m.sup.2 /week given occasionally. Grant et al., supra, pages 42-44 and
Schornagel et al., supra, p. 551. Fatigue, nausea and vomiting are also side effects of the drug, but severity of these events do not appear to correlate with dosage.

Another agent studied for the control of certain cancers is paclitaxel known as TAXOL.RTM.. Paclitaxel was first demonstrated to have activity against refractory ovarian cancer and has subsequently been found to have anti-tumor properties in
some breast cancer patients. Seidman, Annals of Oncology 5 (Suppl. 6):S17-S22 (1994). The primary dose limiting toxic effect of paclitaxel is myelosuppression.

As with the multiple chemotherapeutic drugs available, neither edatrexate nor paclitaxel alone is curative for most metastatic breast cancer patients.

SUMMARY OF THE INVENTION

This invention provides novel combination therapy methods, pharmaceutical combinations and compositions for inducing tumor cell regression in cancer patients, particularly metastatic cancer patients. These methods employ regimens where cancer
patients are treated concurrently with edatrexate and a taxane derivative, preferably paclitaxel, either simultaneously or sequentially. In cancer patients, for example, breast cancer patients, high patient response rates are seen with these treatments. The combination treatment of edatrexate with a taxane surprisingly permits the administration of unusually high dosages of edatrexate, i.e. about 180 mg/m.sup.2 up to a dose of about 400 mg/m.sup.2 without the degree of toxicity found when edatrexate is
administered alone or with other agents. It was further surprising that such high dosages were effective without dose limiting side effects in light of preclinical test results in mice which indicated that the dosage of edatrexate and taxol should be
reduced when the drugs are used together. The mouse data is presented below in Example 1.

Such combination treatments advantageously have application for patients who have chemotherapeutically refractive metastatic breast cancer. The combination treatment described here provides an alternative treatment with a relatively high
response rate which will be beneficial to certain breast cancer patients. Further, the increased patient response levels and the lack of serious side effects seen with these combination treatments, will allow many more patients to become eligible for a
bone marrow transplant program where they would not have otherwise been eligible. Bone marrow transplants are typically only available for patients showing a major response to therapy that does not markedly compromise normal host tissues, viz. bone
marrow. The combination treatments described here will enable patients who have not responded to other treatments an opportunity for this treatment.

DETAILED DESCRIPTION

This invention provides for advantageous combination therapies for cancers, including metastatic breast cancer using regimens which employ administration of a taxane derivative in conjunction with a relatively high dose of edatrexate. The
combination described herein provides a better response rate in metastatic breast cancer patients than either drug alone and surprisingly permits the administration of a high dose of edatrexate. The combination results in a surprising synergy which is
beneficial to many patients in slowing or stopping tumor cell growth in vivo.

The patients to be treated with the combination therapy provided here are those that have been diagnosed with breast cancer, including metastatic breast cancer. Metastatic breast cancer includes, but is not limited to, those cancers occurring in
the breast designated as scirrhous, infiltrative, papillary, ductal, medullary and lobular which have metastasized to other parts of the body, usually by direct extension and via the lymphatics and the bloodstream. Among the most common sites for
metastases are the lungs and pleura, the skeleton and the liver. Distant spread of the disease is usually detected by lymph node biopsy or by x-ray surveys of the skeleton and chest or by liver and bone scans using radioactive isotopes.

One element of the combination therapy described is a taxane derivative. The taxanes are a family of terpenes, including, but not limited to paclitaxel and docetaxel (Taxotere), which were derived primarily from the Pacific yew tree, Taxus
brevifolia, and which have activity against certain tumors, particularly breast and ovarian tumors. Paclitaxel is a preferred taxane. It is considered an antimicrotubule agent that promotes the assembly of microtubules from tubulin dimers and
stabilizes microtubules by preventing depolymerization. This stability results in the inhibition of the normal dynamic reorganization of the microtubule network that is essential for vital interphase and mitotic cellular functions. The term
"paclitaxel" includes both naturally derived and related forms and chemically synthesized compounds or derivatives thereof with antineoplastic properties including deoxygenated paclitaxel compounds such as those described in U.S. Pat. No. 5,440,056,
herein incorporated by reference, and that sold as TAXOLD by Bristol-Myers Oncology. Chemical formulas for paclitaxel are known and can be found in the two previous cited references. For example, in addition to TAXOL.RTM., other derivatives are
mentioned in "Synthesis and Anticancer Activity of Taxol other Derivatives," D. G. I. Kingston et al., Studies in Organic Chemistry, vol. 26, entitled "New Trends in Natural Products Chemistry" (1986), Atta-ur-Rabman, P. W. le Quesne, Eds. (Elvesier,
Amsterdam 1986), pp 219-235 are explicitly included here.

The taxane derivative may be administered in a manner found appropriate by a clinician in generally accepted efficacious dose ranges such as those described in the Physician Desk Reference, 48th Ed. (1994), Publisher Edward R. Barnhart, New
Jersey ("PDR") for paclitaxel. In general, the taxane is administered intravenously at dosages from about 135 to about 300 mg/m.sup.2, preferably from about 135 to about 175 mg/m.sup.2, and most preferably about 175 mg/m.sup.2. It is preferred that the
dosages be administered over a time period of about 1 to about 24 hours, typically over a period of about 3 hours. Dosages can be repeated from 1 to about 4 weeks or more, preferably from about 2 to about 3 weeks.

Provided other formulations of paclitaxel may be tolerated by a patient, the drug may be administered in any other form such as by injection or oral forms. Liposome formulations, for example, have been described. See, e.g. U.S. Pat. No.
5,424,073, which is herein incorporated by reference.

The taxane derivative, preferably paclitaxel, will be administered in the same regimen with edatrexate. It is preferred that the taxane be administered at the same time as edatrexate or after edatrexate has been given to the patient, typically
about 24 hours after edatrexate has been administered. However, the taxane may be administered before edatrexate as well.

Edatrexate (10-ethyl-10-deaza-aminopterin) is a methotrexate analog. Like methotrexate, edatrexate is an inhibitor of dihydrofolate reductase. The structure of edatrexate is shown in Kris et al., Cancer Research 48:5573-5579 (1988) and DeGraw
et al., Current Medicinal Chemistry 2:630-653 (1995) both of which are incorporated by reference herein. The drug was first formulated at Memorial Sloan-Kettering Cancer Center in New York in a collaboration as mentioned above and information regarding
it is available there. Its formulation is also described in U.S. Pat. Nos. 4,369,319 and 4,393,064, and DeGraw et al., supra., and are herein incorporated by reference.

Under the combination therapies described here, edatrexate is administered to a patient in at least one dose of 180 mg/m.sup.2 or greater, preferably from a dose of about 180 mg/m.sup.2 up to about 400 mg/m.sup.2, most preferably in a dose of
about 350 mg/m.sup.2. Though dosages may be given more frequently, such as weekly, if tolerated by the patient, it is preferred that dosages of edatrexate are repeated after a period of about 14 days and more preferably after a period of about 20 days.
In one preferred regimen, edatrexate is administered at escalating doses. More preferably, edatrexate will be administered at a rate of one dose every three weeks for twelve weeks. If the patient responds to the treatment, the treatments will be
repeated.

Edatrexate is administered most conveniently and effectively by intravenous methods. Edatrexate, however, may be available in other forms which will permit alternative modes of administration such as via injection or oral routes. Those too may
be used in a similar manner.

As with the use of other chemotherapeutic drugs, the individual patient will be monitored in a manner deemed appropriate by the treating physician. Typically, no additional drug treatments will occur until, for example, the patient's neutrophil
count is at least 1500 cells/mm.sup.3. Dosages can also be reduced if severe neutropenia or severe peripheral neuropathy occurs, or if a grade 2 or higher level of mucositis is observed, using the Common Toxicity Criteria of the National Cancer
Institute.

The combination therapy agents described here may be administered singly or in a cocktail containing both agents or one of the agents with other therapeutic agents, including but not limited to, immunosuppressive agents, potentiators and
side-effect relieving agents. The therapeutic agents will preferably be administered intravenously or otherwise systemically by injection i.m., subcutaneously, intrathecally or intraperitoneally.

The pharmaceutical compositions of this invention which are found in combination may be in the dosage form of solid, semi-solid, or liquid such as, e.g., suspensions, aerosols or the like. Preferably the compositions are administered in unit
dosage forms suitable for single administration of precise dosage amounts. The compositions may also include, depending on the formulation desired, pharmaceutically-acceptable, nontoxic carriers or diluents, which are defined as vehicles commonly used
to formulate pharmaceutical compositions for animal or human administration. The diluent is selected so as not to affect the biological activity of the combination. Examples of such diluents are distilled water, physiological saline, Ringer's solution,
dextrose solution, and Hank's solution. In addition, the pharmaceutical composition or formulation may also include other carriers, adjuvants, or nontoxic, nontherapeutic, nonimmunogenic stabilizers and the like. Effective amounts of such diluent or
carrier will be those amounts which are effective to obtain a pharmaceutically acceptable formulation in terms of solubility of components, or biological activity, and the like.

In therapeutic applications, the dosages of the agents used in accordance with the invention vary depending on the agent, the age, weight, and clinical condition of the recipient patient, and the experience and judgment of the clinician or
practitioner administering the therapy, among other factors affecting the selected dosage. Generally, the dose should be sufficient to result in slowing, and preferably regressing, the growth of the tumors and also preferably causing complete regression
of the cancer. An effective amount of a pharmaceutical agent is that which provides an objectively identifiable improvement as noted by the clinician or other qualified observer. Regression of a tumor in a patient is typically measured with reference
to the diameter of a tumor. Decrease in the diameter of a tumor indicates regression. Regression is also indicated by failure of tumors to reoccur.

This invention further includes pharmaceutical combinations comprising a taxane derivative and a dose of edatrexate as provided above and kits for the treatment of breast cancer patients comprising a vial of the taxane derivative and a vial of
edatrexate at the doses provided above.

It is understood that the foregoing detailed description and the following examples are illustrative only and are not to be taken as limitations upon the scope of the invention. Various changes and modifications to the disclosed embodiments,
which will be apparent to those skilled in the art, may be made without departing from the spirit and scope of the present invention. Further, all patents, patent applications and publications cited herein are incorporated herein by reference.

EXAMPLES

Example I

Combination treatment in mice. The P388 lymphoidal tumor was transplanted intraperitoneally (10.sup.6 cells/mouse) into B2D51 mice. The animals were randomized into control and treated groups after tumor implant. One day after transplant, the
animals were treated intraperitoneally with either one of two folate analogues, edatrexate (EDX) or methotrexate (MTX), or paclitaxel (TXL) or a combination of folate analogue with paclitaxel on two different schedules (simultaneous or EDX or MTX 24 hr.
before TXL). Therapy was repeated three times at four day intervals between each treatment.

The data show that this tumor was responsive to both folate analogues, with EDX being more effective than MTX. (See Table 1a). Combination therapy with either EDX or MTX with TXL required attenuation of dosage of the antifolate and taxane to
avoid lethal toxicity. EDX with TXL was substantially more effective than MTX with TXL given on the same schedule of administration at the maximum tolerated dose for each combination. Finally, the response was the same when EDX but not MTX were given
either simultaneously or on a sequential schedule. Simultaneous administration of MTX plus TXL was somewhat better than sequential administration. The therapeutic activity of MTX with TXL on either schedule was approximately the same as that obtained
with EDX alone.

Human clinical trials with combination therapy. A Phase I dose escalation trial was designed to enroll cohorts of 5 patients, with each cohort receiving the same dose of edatrexate, adjusted for body surface area, as a 1-hour intravenous
infusion followed approximately 24 hours later by TAXOL.RTM. at 175 mg/m.sup.2 infused intravenously over 3 hours. This dose regimen was repeated every 21 days provided patients demonstrated complete remission (CR), partial remission (PR), improvement
(I) or no change (NC). CR is defined as showing no clinical evidence of tumor, by physical or radiological examination, PR is defined as .gtoreq.50% decrease in the sum of the product of the longest diameter and its longest associated perpendicular of
the tumor, and NC is defined as not meeting the criteria of a complete or partial remission and without the development of new lesions. Patients were withdrawn from the study if there was evidence of progressive disease or unacceptable toxic effects.
The original protocol included three dose levels of edatrexate, 180, 210 and 240 mg/m.sup.2. When no dose limiting toxicity was observed the protocol was amended to include doses of 270, 300, 350 and 400 mg/m.sup.2.

The stated objectives were (1) to establish the maximally tolerated dose (MTD) of edatrexate when given in combination with TAXOL.RTM., (2) to determine the toxicities of the combination, and (3) to establish the noncomparative efficacy of the
combination.

In addition, the data was reviewed in terms of the efficacy of the combination in anthracycline and methotrexate resistant patients. Breast cancer patients who failed on an anthracycline or methotrexate-containing combination chemotherapy
regimen for metastatic disease or relapse within six months of anthracycline or methotrexate-containing adjuvant therapy were considered to be anthracycline or methotrexate resistant.

Results

A total of 36 women with metastatic breast cancer were enrolled in the study. There was excellent compliance of the patients with the following protocol entry criteria: confirmed diagnosis of metastatic disease (32/32 available charts),
Karnofsky performance status of >70% (30/32 available charts), WBC>3000 cells/mm.sup.3 (32/32), platelets .gtoreq.150,000 cells (32/32), creatinine .ltoreq.1.2 mg/dl, (32/32) total bilirubin .ltoreq.1.2 mg/dl (31/32), no radiation or chemotherapy
in the previous three weeks (32/32), no previous TAXOL.RTM. (32/32). Patients were also to be limited to those who had one previous cytotoxic agent; 17 patients had received one, 3 patients had received two cytotoxic agents, 11 had received none, one
was not determined.

Dose Escalation

Dose ascension continued until edatrexate was administered at a dose of 400 mg/m.sup.2 to three patients. All three patients enrolled in the 400 mg/m.sup.2 treatment cohort developed grade 3-4 mucositis. Thus, the maximally tolerated dose for
edatrexate for the general patient population was generally considered to be less than 400 mg/m.sup.2, preferably 350 mg/m.sup.2. (Table 1b)

The median duration of disease at the time of entry into this study was 2.8 years (range 0.1-10.2 years). A total of 76% (25/33) of the patients had received prior anthracycline (45%) or methotrexate (52%) containing chemotherapy. Five of these
patients were considered to be anthracycline (n=4), methotrexate (n=1), or anthracycline and methotrexate (n=1) resistant. A total of 42% (14/33) of the patients received therapy with tamoxifen; 3 received that treatment alone, 9 received chemotherapy
before or after the tamoxifen, and 1 received the tamoxifen treatment with radiation therapy. Thirteen patients (13/33 or 39%) received radiation therapy, all but one in conjunction with other therapies. Two patients, both in the 270 mg/m.sup.2
treatment group had no previous therapies; one had a modified radical mastectomy, the other was newly diagnosed. Previous therapies are summarized in Table 2 as follows:

Although 45% (15/33) of the patients in the 180-350 mg/m.sup.2 treatment groups received an anthracycline (Adriamycin) containing regimen all but four of these patients had not received these regimens within 6 months of recurrence. Similarly,
52% (17/33) of the patients in the 180-350 mg/m.sup.2 treatment groups received a methotrexate containing regimen. All but one of these patients had not received these regimens within 6 months of recurrence of disease. These data are summarized in
Table 3.

Information regarding dose response efficacy can be gleaned from this study. The frequency of CR+PR was 5/6, 3/7, 2/5, 0/5, 2/5 and 3/5 for the 180, 210, 240, 270, 300 and 350 mg/m.sup.2 treatment groups, respectively. Those patients who
responded (CR or PR) were generally entered into a bone marrow transplant study. To qualify for this study they required thorough testing including, but not limited to CAT scan. Because of this, the likelihood of a false positive response in this study
is low. Clinical response by treatment group is provided in Table 4.

The eight patients who had no prior cytotoxic chemotherapy are summarized in Table 6. Five of these patients had received prior tamoxifen with/without radiation therapy, one received radiation alone and two were newly diagnosed with metastatic
breast cancer and were receiving their first therapy as part of this protocol. Two of these eight patients responded to the study regimen.

The regimen of edatrexate followed within 24 hours by TAXOL.RTM. was acceptably well tolerated up to at least 350 mg/M.sup.2 and improved the prognosis of a significant number of the patients. Some patients who were resistant to other
chemotherapeutic agents responded under the combination therapies described above. Further, in a patient population which had been exposed to prior chemotherapy a high overall response rate of 55% was observed.